Respiratory Assessment
Pt. Initials: J.L.
Gender: M
Age: 33
Date: 9/12/17
S:
CC: “Cough”
Mr. J is a 33-year-old white male with a chief complaint of “cough” that has been going
on now for 3 days. Some chest pain with cough rated 3/10 during exacerbation. He
states it seems to have progressively gotten worse with thick green mucus production.
Some SOB is experienced with coughing exacerbation which he states can be up to 15
coughs per minute during these spells, otherwise he notes just intermittent coughing.
Cough is noted to be worse in the morning hours and decreases by night. Endorses that
wife just recently recovered from upper respiratory infection. Patient endorses respiratory
history in maternal grandparents. Cough is low-pitched and deep. No known drug
allergies. Currently uses 2 pillows to sleep at night.
PMH: High cholesterol. Immunizations: flu vaccine- October 2016. PPD 5/2017
negative.
PSH: Denies any surgical history
FH:
Paternal grandfather: Deceased 76, kidney cancer
Paternal grandmother: Living 79, no significant history
Maternal grandfather: Deceased 72, emphysema, smoker
Maternal grandmother: Living 81, smoker, COPD
Mother: Living 60, Smoker, no other significant history
Father: Living 64, high cholesterol
SH: Non-smoker. Currently drinks 1 beer per week. Denies any recreational drug use.
Married. Currently working as registered nurse in acute care setting.
Medication: Prilosec OTC, Tricor 45 mg daily.
General: Endorses low-grade fever (99.9), slight fatigue more than normal. Denies
Malaise.
Cardiac: Denies chest pain currently. Denies swelling. Denies palpitations.
Skin/nails/hair: Denies cyanosis. Denies clubbing of fingers. Denies night sweats.
Pt. Initials: J.L.
Gender: M
Age: 33
Date: 9/12/17
S:
CC: “Cough”
Mr. J is a 33-year-old white male with a chief complaint of “cough” that has been going
on now for 3 days. Some chest pain with cough rated 3/10 during exacerbation. He
states it seems to have progressively gotten worse with thick green mucus production.
Some SOB is experienced with coughing exacerbation which he states can be up to 15
coughs per minute during these spells, otherwise he notes just intermittent coughing.
Cough is noted to be worse in the morning hours and decreases by night. Endorses that
wife just recently recovered from upper respiratory infection. Patient endorses respiratory
history in maternal grandparents. Cough is low-pitched and deep. No known drug
allergies. Currently uses 2 pillows to sleep at night.
PMH: High cholesterol. Immunizations: flu vaccine- October 2016. PPD 5/2017
negative.
PSH: Denies any surgical history
FH:
Paternal grandfather: Deceased 76, kidney cancer
Paternal grandmother: Living 79, no significant history
Maternal grandfather: Deceased 72, emphysema, smoker
Maternal grandmother: Living 81, smoker, COPD
Mother: Living 60, Smoker, no other significant history
Father: Living 64, high cholesterol
SH: Non-smoker. Currently drinks 1 beer per week. Denies any recreational drug use.
Married. Currently working as registered nurse in acute care setting.
Medication: Prilosec OTC, Tricor 45 mg daily.
General: Endorses low-grade fever (99.9), slight fatigue more than normal. Denies
Malaise.
Cardiac: Denies chest pain currently. Denies swelling. Denies palpitations.
Skin/nails/hair: Denies cyanosis. Denies clubbing of fingers. Denies night sweats.
